Journal of Gerontological Nursing

Research Brief Supplemental Data

Feasibility of an Integrative Activity Program for Older Adults With Low Education and Mild Dementia

Sunghee Hong Tak, PhD, MPH, RN; Ji-yeon Kim, MSN, RN; Hana Ko, PhD, GNP, RN; Yeung Min Yoo, RN

Abstract

The population of older adults is increasing, as is the number of older adults with dementia. However, there is a lack of integrative interventions that include both cognitive training and physical exercise for older adults with dementia. The current study conducted a 12-week integrated program for older adults with low education and mild dementia; the study modified the contents developed by the National Dementia Institute. Effects of the integrated program were examined in 30 participants (16 from the experimental group and 14 from the control group). Analysis showed that the tailored integrated program increased the cognitive function of participants in the experimental group. The findings of this study suggest that using therapeutic strategies and providing person-centered care are necessary for older adults with low educational backgrounds and low literacy levels. [Journal of Gerontological Nursing, 45(3), 13–20.]

Abstract

The population of older adults is increasing, as is the number of older adults with dementia. However, there is a lack of integrative interventions that include both cognitive training and physical exercise for older adults with dementia. The current study conducted a 12-week integrated program for older adults with low education and mild dementia; the study modified the contents developed by the National Dementia Institute. Effects of the integrated program were examined in 30 participants (16 from the experimental group and 14 from the control group). Analysis showed that the tailored integrated program increased the cognitive function of participants in the experimental group. The findings of this study suggest that using therapeutic strategies and providing person-centered care are necessary for older adults with low educational backgrounds and low literacy levels. [Journal of Gerontological Nursing, 45(3), 13–20.]

Dementia affects memory and other cognitive abilities, and impaired cognition interferes with daily life. Worldwide, 50 million individuals have dementia (Alzheimer's Disease International, 2018). Alzheimer's disease (AD), accounting for approximately 60% to 80% of all cases of dementia, afflicts one of every 10 individuals ages 65 and older and approximately one third of individuals older than 85 (Alzheimer's Association, 2018). Approximately one case of AD is diagnosed every 3 seconds, amounting to approximately 9.9 million new cases of dementia each year (Prince et al., 2015). This number is almost doubled every 20 years (Prince et al., 2015).

The course of the disease and the rate at which changes occur vary between individuals. On average, older adults live from 8 to 10 years after diagnosis, but may live as long as 20 years. In terms of health care expenses and lost wages of individuals with AD and their caregivers, the cost of AD is a staggering $80 to $100 billion per year. AD ranks third, with respect to health care costs, after heart disease and cancer (Luengo-Fernandez, Leal, & Gray, 2015). AD is also a leading cause of institutionalization; one half of all nursing home residents have AD or a dementia-related disorder (Alzheimer's Association, 2018). As the disease progresses, major behavioral symptoms, such as agitation, are manifested along with limitations in physical functioning. These behaviors overburden families and often precipitate institutionalization.

Previous studies show that physical exercise and cognitive interventions are effective in improving cognitive ability in older adults with mild dementia or mild cognitive impairment (Li et al., 2011; Wang et al., 2014). Use of cognitive techniques such as errorless learning, spaced-retrieval training, vanishing cues, or verbal instruction/cueing can improve brain plasticity of individuals with dementia (Hopper et al., 2013; Li et al., 2011). In recent years, cognitive interventions have often been provided using electronic devices such as voice recorders, electronic reminders, and computers (Brougham, 2009). Evidence shows that language ability is preserved and daily life is relatively close to normal in individuals with mild cognitive impairment when cognitive interventions are provided (Jeong, Sung, & Sim, 2014; Li et al., 2011; Wang et al., 2014).

In addition, many types of physical exercise programs have shown cognitive benefits for older adults with mild cognitive impairment; of these, aerobic exercise, walking, and tai chi are most common (Cai & Abrahamson, 2016). The duration of the physical exercise programs varies, with a minimum of 10 weeks (Cai & Abrahamson, 2016). There is no doubt that physical exercise is beneficial for older adults with cognitive impairment or dementia, as physical exercise can reduce the risk of factors related to cardiovascular disease, such as hypertension, which may ultimately decrease the possibility of cognitive decline (Grodstein, 2007). Nonetheless, despite the single domain approach to dementia or cognitive decline, multi-domain interventions seem to be more effective in delaying disease progression (Brasure et al., 2018; Öhman, Savikko, Strandberg, & Pitkälä, 2014; Stephen, Hongisto, Solomon, & Lönnroos, 2017). In previous studies, integrative programs for older adults with mild cognitive impairment have been effective for 8 to 12 weeks (Dannhauser et al., 2014; Kolanowski, Litaker, Buettner, Moeller, & Costa, 2011).

To date, there is lack of an integrated intervention that includes both cognitive training and physical exercise for older adults with dementia. Furthermore, a standardized activity program is not appropriate for older adults with no formal education or low educational levels. Evidence indicates that many clinical trials have failed in real-life settings because they do not address individuals' cognitive or functional abilities, contributing to nonadherence (Beck et al., 2010). Older adults with dementia do not engage in activities that are strictly programmed or are not appropriately matched to their abilities (Tak & Hong, 2014). Person-centered care also emphasizes that activity programs should account for the various strengths and capabilities of individuals with dementia (Doyle & Rubinstein, 2013). According to Cowan (2004), education needs to be modified for individuals with low literacy levels so that they can engage, process information, and gain knowledge and skills. Effective educational methods include verbal instructions, repetition or review of the instructions, demonstration and return demonstration, and teaching in small increments.

Therefore, the purpose of the current study was to evaluate the effects of an integrated program on cognitive function and health outcomes and to examine barriers to and difficulties of delivering such programs for older adults with low education and mild dementia.

Method

The current study used a pretest/posttest nonequivalent control group design to examine the effects of the 12-session integrated activity program for older adults with low education and mild dementia. Effects on cognitive ability, psychological state, and physical health status were measured.

Participants

After Institutional Review Board (IRB) approval, study participants were recruited from a senior citizen center. Potential participants were contacted by either a RN or social workers at the center. Participants came regularly and spent their daytime hours at the center. Participants had to meet the following criteria: (a) age ≥65 years, and (b) receive a score between 20 and 23 on the Korean version of the Mini Mental State Examination (MMSE-K; Kwon & Park, 1989). Older adults with acute illness or major deficits in hearing and sight even with use of hearing aids and glasses were excluded. The 33 participants who were recruited were conveniently assigned to the experimental and control groups. However, one participant dropped out due to hospitalization and two participants were eliminated due to non-completion of the program. A total of 30 participants completed the study, with 16 participants in the experimental group and 14 participants in the control (usual care) group.

Integrated Activity Program

Over a 10-week period, researchers provided the program once per week for 8 weeks and twice per week for the last 2 weeks. The 12-session intervention program was conducted in an open-area exercise room at a senior citizen center in Seoul, South Korea. Each intervention comprised a short educational, physical, and cognitive activity. The physical, cognitive, and educational material was modified from that of the National Dementia Center (2017).

Every session was divided into three parts, each of which began with a 20-minute physical exercise component based on teuroteu music, which was the favored and familiar genre among participants. The music was changed every four sessions; a total of three songs were mastered during the program. Researchers taught participants various gestures and moves, which were modified dance movements based on preventive exercises provided by the National Dementia Center (2017). Movements included clapping (e.g., clapping over the head, on the shoulders, on the buttocks; fist and fingertip clapping); arm exercise (e.g., reaching arms over the head and to the sides, crossing arms in front of chest); and head exercise (e.g., rotating the neck to the right and left, turning it in circles). An instructor trained participants on dance movements for the first 10 minutes and repetitive movements for the next 10 minutes. If older adults experienced fatigue during the physical activity, they were advised to sit and relax as needed. Older adults had to demonstrate the next movement in the dance sequence when the instructor conducted a quiz based on the dance movements learned. This activity was to encourage older adults to memorize the movements in order.

The second part was a 5- to 10-minute short educational session on dementia. The contents included facts about dementia, resources for dementia care, and preventive behavior for dementia; information was provided to participants, who were free to ask questions.

The last part, cognitive activity, was inspired by and adapted from the “do-geun do-geun” brain activity developed by the National Dementia Center (2017). Researchers had to revise the intervention due to the low educational background and literacy level of participants. Cognitive activities had to be modified to render them entertaining, easy to follow and memorize, and repetitive, and to ensure that the activities did not require reading or writing skills. Specifics of the original and modified activities are listed in Table A (available in the online version of this article).

Originally Planned Cognitive Activity and What Was Changed

Table A:

Originally Planned Cognitive Activity and What Was Changed

Ethical Consideration

Approval from the university's IRB was obtained prior to data collection. Study participants provided signed consent forms. All personal information was coded to numbers to protect participants' confidentiality and was kept in a locked cabinet, complicit with regulations.

Measures

Participants needed assistance when answering the questionnaire. For older adults who were not able to read and write, researchers had to read the questions and write down the response that the older adult had given.

Demographic data, including gender, age, living situation, use of the senior citizen center, economic status, educational level, number of medications taken, and smoking or alcohol consumption habits, were measured. In addition, body mass index (BMI) was used to observe the objective physical condition of participants.

Cognition level was measured using the MMSE-K (Kwon & Park, 1989). The MMSE-K is a measure of cognitive function; scores range from 0 to 30. The MMSE-K comprises 20 questions related to various domains (e.g., attention, language, word recall, orientation to time and place). Higher scores indicate better cognitive function.

The Verbal Fluency (VF) test, clock drawing test, and Trail Making Test (TMT) parts A and B in the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD-K; Lee et al., 2002; Woo et al., 2003) were used to measure executive functions. For the VF test, participants were asked to name as many animals as possible within 1 minute; a higher number of animals named indicated better executive function. The VF test has been shown to have substantial test–retest reliability and to be sensitive to changes in individuals with dementia (Morris et al., 1989).

The TMT parts A and B are the subitems of the CERAD-K, a test that involves drawing a line to randomly connect the arranged circled number or circled Korean characters in a certain order as fast as possible. TMT part A has 25 circled numbers. The purpose of TMT part A is mainly to evaluate attention, sequencing ability, ability to search time and space, cognitive ability, and motor skills. TMT part B has 13 circled numbers and 12 circled Korean characters that must be connected alternately. TMT part B, with abilities tested in TMT part A, evaluates psychological flexibility. There is a time limit for both tests (360 seconds for TMT part A and 300 seconds for TMT part B) (Lee, Park, & Lim, 2013; Woo et al., 2003). However, in the current study, researchers were not able to perform TMT parts A and B due to participants' difficulty understanding the instructions and illiteracy.

The measurement tool Dementia Preventive Behavior was developed by Lee, Woo, Kim, Lee, and Im (2009). The tool has 12 items; each item can be scored from 1 to 3. Total scores range between 12 and 36, with higher scores indicating better performance of dementia preventive behavior (Lee et al., 2009).

The Korean Frailty Index was developed by Hwang et al. (2010). General health status (including number of hospitalizations and subjective health condition), drug consumption, nutritive conditions (weight loss), emotional status (depression), urinary incontinence, ambulatory ability, and communication (vision and hearing) disorders were the eight items measured; each item was measured as a dichotomous scale (i.e., 0 or 1). Total scores ranged from 0 to 8, with higher scores indicating greater frailty.

A depression measurement tool was developed by Yesavage et al. (1983) and modified by Cho et al. (1999) to create a Korean version of the Geriatric Depression Scale. There are 15 questions; each question is given a score of 0 or 1, with a total score ranging from 0 to 15. Higher scores indicate higher levels of depression (Cho et al., 1999).

The Euro Quality of Life-5 Dimension-5 Level (EQ-5D-5L) used in the current study is the official version provided by the EuroQol Group to measure quality of life. Mobility, self-care, usual activities, pain/discomfort, and anxiety/depression are the five domains of the EQ-5D-5L. Each domain is scaled as five levels, from no problem to extreme problems. The EQ-5D-5L health states are defined by combining one level from each of the five dimensions for a total of 3,125 possible health states. For example, 11111 indicates no problems on any of the five domains, whereas 55555 indicates extreme problems on all five domains (Kim et al., 2016).

Data Analyses

Continuous variables were reported as mean and standard deviations when normally distributed and categorical variables were presented as numbers and percentages. Comparison of baseline characteristics between the control and intervention groups was performed using a chi-square test (for categorical variables), independent t test (for normally distributed variables), or Mann-Whitney U test (for non-normally distributed continuous variables). Differences between pre- and postintervention scores (delta scores) of the baseline and outcome scores were calculated for each assessment scale. To compare delta scores within and between the control and intervention groups, Wilcoxon signed ranked test and Mann-Whitney U tests were used, respectively. A two-sided statistical significance level of p < 0.05 was set. SPSS 22.0 was used for data analysis.

Results

Participant Demographics

Table 1 shows characteristics of study participants. The mean age of study participants was 81.93 years, and there was only one male participant in the control group. Approximately one half of participants lived alone, and most participants' spouses were deceased. No participants were employed, and all stated that their economic status was either low or middle income.

Characteristics of Participants

Table 1:

Characteristics of Participants

Participants in both groups had not received education higher than elementary school. In the experimental group, five participants were illiterate; eight were illiterate in the control group. Most participants stated that they did not drink, with the exception of one participant in each group, and none of the participants smoked. Seventy-five percent (n = 12) of the experimental group and 64% (n = 9) of the control group reported exercising regularly. A homogeneity test showed no significant differences between groups.

Cognitive and Health Outcomes

Effects of the Integrated Activity. For the experimental group, the post-intervention MMSE-K score was significantly higher than that of the control group (−2.665, p = 0.013). There was no significant difference between groups for quality of life, VF, dementia prevention, BMI, depression, and frailty scores. However, the quality of life score as measured by the EQ-5D-5L decreased from 13 (SD = 4.29) to 12.06 (SD = 4.31) in the control group and increased from 10.42 (SD = 4.20) to 11.37 (SD = 4.99) in the experimental group. The dementia prevention score of the experimental group increased from 26.93 (SD = 3.97) to 29.12 (SD = 2.80), whereas the control group showed no difference. The BMI of the experimental group decreased slightly and the control group showed no difference. The control group showed no difference in the depression scale; however, the experimental group had lower depression scores after the intervention (Table 2).

Comparison of Pre- and Post-Test Scores for Outcome Measures

Table 2:

Comparison of Pre- and Post-Test Scores for Outcome Measures

Difficulties and Alternatives. Due to low educational levels and illiteracy of participants, the originally planned cognitive activity could not be used. Researchers had to modify and replace the initial activity. First, researchers had to eliminate all contents that required reading and writing. For example, in the fifth session, the original cognitive activity was to read a written phrase out loud while emphasizing different words. Participants were given a phrase that was unfamiliar. The phrase was also provided in a PowerPoint® slide so participants could view it when needed. Participants were asked to emphasize different words and to repeat the phrase until the emphasis was on the last word. However, participants were not able to memorize the phrase, nor were they able to remember the phrase by referring to the PowerPoint slide provided due to illiteracy. Thus, researchers modified the program by providing a familiar phrase so that it would be easy to recall.

Second, researchers had to eliminate all contents that required complex cognitive abilities, such as calculation. For example, in the ninth session, the original cognitive activity was called “unraveling the phrase.” Participants were given a title of a newspaper article. First, they had to write down the number of words in the title. Then, they were asked to read only the initial consonant of the Korean orthographic syllable of the whole title aloud, followed by the medial consonant, and then the final consonant of the title. They were to measure the time taken and record it. However, this activity required participants to read the title of the article and recognize the initial, medial, and final consonant of the Korean orthographic syllable, which was too complex for participants. Thus, researchers had to replace this activity with an activity that did not involve reading or writing.

The activity was changed to “finding the wrong pictures,” in which participants were given a picture with hidden objects. Participants were told the name of an object and asked to find the object in the picture. Most of the cognitive activities had to be modified or replaced. Table A provides a detailed explanation of the originally planned activities, the cognitive task required to complete these activities, and how researchers increased activity engagement (modified or replaced cognitive activity).

Discussion

The integrated activity program contained physical exercise and cognitive activity; the activity program was tailored for older adults with low education and mild dementia. The current study was conducted to develop an integrated program to provide person-centered dementia prevention intervention and examine the program's effects. Findings of this study indicate that special considerations are required in the planning phase of an integrated activity intervention for individuals with low education and mild dementia. Because written texts or materials cannot be used, the form and contents of activity programs may be greatly limited.

Tailored strategies are necessary to deliver such activity programs for the population. Additional visual aids to materials, such as video or pictorial aids; repetition of the intervention; teach-to-goal strategies (i.e., to check understanding after each session and confirm mastery of learning goals; Baker et al., 2011); and therapeutic monitoring and communication with a primary care provider, if possible (Barnason et al., 2017), are required. Researchers had to modify and replace the original program due to low educational background and illiteracy of participants. The research team eliminated all activities that involved reading, writing, calculation, and complex cognitive skills. Results showed that this integrative program improved the cognitive ability of participants. The current researchers believe that the program was effective because they replaced the cognitive activity with visual and auditory supplements instead of words. Researchers also modified individual activities into group activities. Instructions were repetitively provided to participants and interactive communication was used during the cognitive activity. By applying these changes to the original cognitive activity, tailored cognitive activity was provided to participants.

Results show that this integrated program did not have any effect on depression. This finding could be due to the content of the integrated program. The content did not cover emotions or feelings of participants or their social engagement. As depression is a major risk factor for dementia and has been known to worsen dementia symptoms, it is important to include activities that can improve participants' depression level.

In the planning phase of this study, the research team was not aware of the educational levels and illiteracy of participants. Hence, the original plans of the cognitive activities had to be changed and modified during the study. After completing the study, researchers cogitated on the effectiveness of the original program based on the educational and literacy level of participants and believe that this program would have been more effective.

The dementia prevention program developed by the National Institute of Dementia in Korea is not applicable for older adults with low educational or literacy levels. The program requires the ability to read, write, and follow complex instructions. Thus, there is a need for development of dementia prevention programs for illiterate older adults and older adults with low educational backgrounds.

Researchers added TMT parts A and B as a measurement tool to assess participants' cognitive abilities; however, this instrument was not appropriate for the current participants. TMT parts A and B require reading skills and knowledge of the order of the alphabet. It is important to consider participants' ability and requirements when choosing the instrument.

As there were many major changes during the study period, the program and study were not conducted according to the original plan. However, the program was tailored, and it provided person-centered care for participants. Results also showed that the program was effective in improving cognitive function for older adults with dementia who had low educational backgrounds and difficulty reading and writing.

Limitations

In the current study, participants were recruited through convenience sampling and the control group and experimental group were able to communicate with one another; in future studies, participants should be recruited from different settings to prevent internal validity of the study. Randomization of the sample is recommended for future studies to prove effectiveness of this integrative program. Another limitation of the current study is that it was conducted in one specific area of Seoul, South Korea. Regional characteristics, such as low socioeconomic status, may have influenced participants' characteristics. To improve validity of the results, it is necessary to broaden the sample, diversify study variables, and conduct more longitudinal studies to produce wide-ranging results.

Conclusion

Preventing and slowing symptoms of dementia are important factors in dementia care. The current study helps understand the importance of literacy level and educational background when assessing physical and cognitive activities of older adults with dementia. The study also provides a guideline (with modified or replaced activities) on how to plan the program and implement person-centered cognitive activities. It is important to provide tailored dementia prevention programs for older adults with low educational backgrounds and literacy levels.

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Characteristics of Participants

Characteristicn (%)
Experimental Group (n = 16)Control Group (n = 14)
Agea (years) (mean [SD])80.81 (4.75)83.21 (5.59)
Gender
  Female16 (100)13 (92.9)
  Male01 (7.1)
Living situation
  Alone9 (56.3)7 (50)
  With spouse2 (12.5)2 (14.3)
  With two generations of family5 (31.3)4 (28.6)
  With three generations of family01 (7.1)
Marital status
  Widowed14 (87.5)12 (85.7)
  Married2 (12.5)2 (14.3)
  Unemployed16 (100)14 (100)
Economic status
  Middle income8 (50)9 (64.3)
  Low income8 (50)5 (35.7)
Educational level
  No education13 (81.3)8 (57.1)
    Literate8 (50)0
    Illiterate5 (31.3)8 (57.1)
  Elementary school3 (18.8)6 (42.9)
Regular alcohol consumption
  No15 (93.8)13 (92.9)
  Yes1 (6.3)1 (7.1)
Nonsmoker16 (100)14 (100)
Regular exercise
  Yes12 (75)9 (64.3)
  No4 (25)5 (35.7)

Comparison of Pre- and Post-Test Scores for Outcome Measures

Outcome MeasureMean (SD) (Range)t Testap Value
Experimental Group (n = 16)Control Group (n = 14)
PrePostPrePost
Quality of lifeb12.06 (4.31) (6 to 21)11.37 (4.99) (5 to 24)13.00 (4.29) (5 to 18)10.42 (4.20) (5 to 19)−1.31NS
Cognitive functionc21.50 (1.26) (20 to 24)24.81 (2.78) (20 to 24)21.35 (1.49) (20 to 25)21.78 (4.29) (12 to 30)−2.660.013*
Verbal fluencyd9.37 (2.41) (6 to 13)9.87 (4.16) (0 to 18)8.54 (4.73) (3 to 23)8.79 (3.68) (3 to 15)−0.29NS
Dementia preventive behaviore26.93 (3.97) (21 to 34)29.12 (2.80) (24 to 34)26.28 (3.56) (18 to 30)26.78 (3.59) (21 to 34)−1.39NS
Body mass index27.50 (2.86) (22.2 to 33.0)26.70 (3.06) (21.2 to 33.4)26.58 (4.30) (20.2 to 34.6)26.32 (4.00) (19.5 to 33.7)1.08NS
Depressionf7.81 (3.25) (3 to 14)5.81 (4.06) (1 to 13)8.71 (3.81) (2 to 13)8.00 (3.25) (1 to 13)1.09NS
Frailtyg3.25 (1.39) (2 to 7)3.19 (1.86) (0 to 7)3.35 (1.59) (0 to 6)2.71 (1.77) (0 to 7)−1.12NS

Originally Planned Cognitive Activity and What Was Changed

Original Program (What we planned)(What we did)
original activitycomments & difficultiesmodified/replaced activity
Calendar calculator : calculation of the numbers in the same rowdifficulties with the calculation

slow down the speed of the activity

provided individual assistant

Traveling with the weather map : connecting the cities, by temperature in ordernot able to scan the weather map in whole, and to find the lowest & highest temperature

slow down the speed of the activity

provided individual assistant

Memorizing names : memorizing the name by making an acrostic poemnot able to make the acrostic poem & they were illiterate.

group made an acrostic poem together

Memorizing lyricsParticipants were illiterate.

memorized the lyrics by movements

Alternating the accents out loud : alternating accents on each word in the phraseParticipants were illiterate.

familiar phrase was given

Puzzle scrapping : making a puzzle out of an article and putting it back togetherParticipants were illiterate.

given a picture of mountains and flowers instead of an article.

Interchanging rhythms and lyrics : singing the lyrics to a different song melodyParticipants were illiterate. Modified two songs that were familiar to the participants.

participated as a group together

Memorizing the title : writing the title of an article and recalling it an hour laterParticipants were illiterate Replaced activity with no reading or writing.Finding hidden pictures : given two pictures that look almost alike and asked to find the difference in two pictures.
Unraveling the phrase : reading the initial (medial, final) consonant of the title.Participants were illiterate. Replaced activity with no reading or writing.Finding wrong pictures : given a picture that has objects hidden asked to find them
Connecting the alphabets : finding the longest word in the article in alphabetical orderParticipants were illiterate. Replaced activity with no reading or writing.Digit drawing : finding the smallest number and connect the dots in order to complete a picture
Making the schedule : circling the program on the TV guide and plan for a walk for that amount of timeParticipants were illiterate and not able to calculate. Replaced activity that does not involve reading, writing and calculation.Drawing the same picture : drawing the same figure that is given
Do you remember? : recalling the memories with a picture of a big eventParticipants were illiterate. Replaced writing their feeling and memory by verbal presentation.Wrap-up of the 11 weeks and shared experience and feelings during the program.
Authors

Dr. Tak is Professor, Research Institute of Nursing Science, Ms. Kim is Doctoral Student, College of Nursing, Dr. Ko is Research Assistant, Research Institute of Nursing Science, and Ms. Yoo is Master's Student, College of Nursing, Seoul National University, Seoul, South Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by the Research Resettlement Fund for new faculty of Seoul National University.

Address correspondence to Ji-yeon Kim, MSN, RN, Doctoral Student, College of Nursing, Seoul National University, Daehakro 103, Jongno-Gu, Seoul, South Korea 03080; e-mail: pennpaper421@gmail.com.

Received: February 12, 2018
Accepted: October 22, 2018

10.3928/00989134-20190124-01

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